How the Trans Pacific Partnership Agreement could undermine PHARMAC and threaten access to affordable medicines and health equity in New Zealand

The commercial determinants of Indigenous health and well-being: a systematic scoping review

INTRODUCTION

Health inequity within Indigenous populations is widespread and underpinned by colonialism, dispossession and oppression. Social and cultural determinants of Indigenous health and well-being are well described. Despite emerging literature on the commercial determinants of health, the health and well-being impacts of commercial activities for Indigenous populations is not well understood. We aimed to identify, map and synthesise the available evidence on the commercial determinants of Indigenous health and well-being.

METHODS

Five academic databases (MEDLINE Complete, Global Health APAPsycInfo, Environment Complete and Business Source Complete) and grey literature (Australian Indigenous HealthInfoNet, Google Scholar, Google) were systematically searched for articles describing commercial industry activities that may influence health and well-being for Indigenous peoples in high-income countries. Data were extracted by Indigenous and non-Indigenous researchers and narratively synthesised.

RESULTS

56 articles from the USA, Canada, Australia, New Zealand, Norway and Sweden were included, 11 of which were editorials/commentaries. The activities of the extractive (mining), tobacco, food and beverage, pharmaceutical, alcohol and gambling industries were reported to impact Indigenous populations. Forty-six articles reported health-harming commercial practices, including exploitation of Indigenous land, marketing, lobbying and corporate social responsibility activities. Eight articles reported positive commercial industry activities that may reinforce cultural expression, cultural continuity and Indigenous self-determination. Few articles reported Indigenous involvement across the study design and implementation.

CONCLUSION

Commercial industry activities contribute to health and well-being outcomes of Indigenous populations. Actions to reduce the harmful impacts of commercial activities on Indigenous health and well-being and future empirical research on the commercial determinants of Indigenous health, should be Indigenous led or designed in collaboration with Indigenous peoples.

When actions do not match aspirations - comparison of the European Union policy claims against what has been negotiated for health services, trade and investment

Background

Obligations arising from trade and investment agreements can affect how governments can regulate and organise health systems. The European Union has made explicit statements of safeguarding policy space for health systems. We assessed to what extent health systems were safeguarded in trade negotiations using the European Union (EU) negotiation proposals for the Transatlantic Trade and Investment Partnership (TTIP) and the negotiated agreement for the EU-Canada Comprehensive Economic and Trade Agreement (CETA).

Methods

We assessed if and to what extent the European Union policy assurances were upheld in trade negotiations. Our assessment was made using three process tracing informed tests. The tests examined: i) what was covered in negotiation proposals of services and investment chapters, ii) if treatment of health services differed from treatment of another category of services (audiovisual services) with similar EU Treaty considerations, and iii) if other means of general exceptions, declarations or emphases on right to regulate could have resulted in the same outcome.

Results

Our analysis shows that the European Union had sought to secure policy space for publicly funded health services for services chapter, but not for investment and investment protection chapters. In comparison to audiovisual services, exceptions for health services fall short from those on audiovisual services. There is little evidence that the same outcome could have been achieved using other avenues.

Conclusions

The European Union has not achieved its own assurances of protection of regulatory policy space for health services in trade negotiations. The European Union trade negotiation priorities need to change to ensure that its negotiation practices comply with its own assurances for health services and sustainable financing of health systems.

Projected spending for brand-name drugs in English primary care given US prices: a cross-sectional study

Objectives

To estimate additional spending if NHS England paid the same prices as US Medicare Part D for the 50 single-source brand-name drugs with the highest expenditure in English primary care in 2018.

Design

Retrospective analysis of 2018 drug prescribing and spending in the NHS England prescribing data and the Medicare Part D Drug Spending Dashboard and Data. We examined the 50 costliest drugs in English primary care available as brand-name-only in the US and England. We performed cost projections of NHS England spending with US Medicare Part D prices. We estimated average 2018 US rebates as 1 minus the quotient of net divided by gross Medicare Part D spending.

Setting

England and US

Participants

NHS England and US Medicare systems

Main outcome measures

Total spending, prescriptions and claims in NHS England and Medicare Part D. All spending and cost measures were reported in 2018 British pounds.

Results

NHS England spent £1.39 billion on drugs in the cohort. All drugs were more expensive under US Medicare Part D than NHS England. The US–England price ratios ranged from 1.3 to 9.9 (mean ratio 4.8). Accounting for prescribing volume, if NHS England had paid US Medicare Part D prices after adjusting for estimated US rebates, it would have spent 4.6 times as much in 2018 on drugs in the cohort (£6.42 billion).

Conclusions

Spending by NHS England would be substantially higher if it paid US Medicare Part D prices. This could result in decreased access to medicines and other health services.

Talkin' About a Resolution: Issues in the Push for Greater Transparency of Medicine Prices

At the 2019 World Health Assembly, a significant new resolution was agreed by most countries to start publicly sharing information on the real net prices they pay for medicines in their health systems. The resolution also includes provisions for countries to support other transparency activities. However, an additional proposal to require pharmaceutical companies to submit information on their internal sales figures, internal research and development costs, clinical trial costs and marketing costs for each individual medicine as a condition of registration, and for governments to publish this, was not agreed. Pressure for coordinated international action to increase the transparency of medicine prices and costs has been building for some time, as confidential discounts and rebates on prices of medicines are common. We argue that while it is possible that stakeholders may benefit to some extent from greater transparency on prices, several important policy and economic issues need to be carefully considered. Such transparency, combined with widespread use of international reference pricing, might undermine companies' differential pricing strategies, which are important in fostering wider access to medicines in low- and middle-income countries in particular, noting that access to medicines issues can occur in high-income countries as well. Moreover, there is a further risk that these types of proposals will lead to price fixing, less competition and higher prices than might otherwise be the case. The lack of any commitments in the resolution to greater transparency in payer decision-making processes also risks undermining the credibility of the resolution. The resolution and further transparency measures could have the potential to undermine patient access to medicines in the developing world, lead to higher prices in some markets and compromise long-term development of new medicines for future generations.

Trans-Pacific Partnership Agreement and Its Impact on Accessibility and Affordability of Medicines: A Meta-synthesis

This article aims to discuss the main consequences of the implementation of the Trans-Pacific Partnership Agreement (TTPA) in the pharmaceutical sector in regard to public health, focusing on the accessibility and affordability of medicines. This paper also looks at the likely impact of the TPP agreement on access to affordable medicines. The potential effects of provisions in the final text are explored based on the context of developed and developing countries. A meta-synthesis study design was used. The thematic analysis technique was used to generate themes and a decision tree of the TTPA meta-synthesis. PubMed, EBSCOhost, Ovid, and Scopus databases from inception until the first week of January 2016 were used. Only peer-reviewed journals that discussed TPPA's impact on the pharmaceutical sector were included. Data were extracted by 2 reviewers and then verified by 3 senior researchers. The extracted data were imported into Excel spreadsheets and coded line by line. Codes were organized into descriptive themes. The identified themes were cross-checked against original articles to ensure consistency. A total of 85 full articles and reports were reviewed and, finally, 32 of them were used in the meta-synthesis. Two central themes to the TTPA emerged: intellectual property rights and transparency. Five subthemes were identified under intellectual property rights: patent subject matter (representing scope of patentability), patent term adjustment for patent office delays (representing patent term extension), protection of undisclosed test or other data (representing data exclusivity), protection of undisclosed test or other data (representing patent linkage), and compulsory licensing. Meanwhile, transparency and anti-corruption-procedural fairness, which presents restriction of coverage program and reimbursement, were identified as the subthemes of transparency. Findings indicate that the TPPA could potentially hinder the affordability and accessibility of medicine, which could increase risks to public health.

Advancing Public Health on the Changing Global Trade and Investment Agenda Comment on "The Trans-Pacific Partnership: Is It Everything We Feared for Health?"

Concerns regarding the Trans-Pacific Partnership (TPP) have raised awareness about the negative public health impacts of trade and investment agreements. In the past decade, we have learned much about the implications of trade agreements for public health: reduced equity in access to health services; increased flows of unhealthy commodities; limits on access to medicines; and constrained policy space for health. Getting health on the trade agenda continues to prove challenging, despite some progress in moving towards policy coherence. Recent changes in trade and investment agendas highlight an opportunity for public health researchers and practitioners to engage in highly politicized debates about how future economic policy can protect and support equitable public health outcomes. To fulfil this opportunity, public health attention now needs to turn to strengthening policy coherence between trade and health, and identifying how solutions can be implemented. Key strategies include research agendas that address politics and power, and capacity building for both trade and health officials.

What is policy and where do we look for it when we want to research it?

Public health researchers are increasingly concerned with achieving 'upstream' change to achieve reductions in the global burden of disease and health inequalities. Consequently, understanding policy and how to change it has become a central goal of public health. Yet conceptualisation of what constitutes policy and where it can be found is very limited within this field. Our glossary demonstrates that policy is many headed. It is located in a vast array of documents, discussions dialogues and actions which can be captured variously by formal and informal forms of documentation and observation. Effectively understanding policy and its relevance for public health requires an awareness of the full range of places and contexts in which policy work happens and policy documents are produced.

Commentary: Moving towards policy coherence in trade and health

International trade has brought economic benefits to many countries, but the association of trade and investment liberalisation with poor health outcomes concerns the public health community. The need to secure more 'healthy' trade is a recognised priority, especially as countries move from global to regional/bilateral trade agreements - with greater public health risks. However, a transition towards 'healthier trade' may be hindered by worldview differences between the trade and health communities. There is a tendency for health actors to perceive trade as a threat to population health, and for trade actors to view health as a constraint to trade objectives of reducing barriers to cross-border commercial flows and economic growth. Unless such differing worldviews can be aligned, finding ways forward for addressing public health in trade policy is likely to be difficult. Moving forward will involve understanding the values and drivers of the respective groups, and developing solutions palatable to their various interests. Given the power imbalances between the two areas, it is likely that the health community will have to make the first moves in this respect. This article outlines the key issues involved and suggests areas where such moves have been, and may be made.

Improving regulatory capacity to manage risks associated with trade agreements

Modern trade negotiations have delivered a plethora of bilateral and regional preferential trade agreements (PTAs), which involve considerable risk to public health, thus placing demands on governments to strengthen administrative regulatory capacities in regard to the negotiation, implementation and on-going management of PTAs. In terms of risk management, the administrative regulatory capacity requisite for appropriate negotiation of PTAs is different to that for the implementation or on-going management of PTAs, but at all stages the capacity needed is expensive, skill-intensive and requires considerable infrastructure, which smaller and poorer states especially struggle to find. It is also a task generally underestimated. If states do not find ways to increase their capacities then PTAs are likely to become much greater drivers of health inequities. Developing countries especially struggle to find this capacity. In this article we set out the importance of administrative regulatory capacity and coordination to manage the risks to public health associated with PTAs, and suggest ways countries can improve their capacity.

Ahead of its time? Reflecting on New Zealand's Pharmac following its 20th anniversary

New Zealand's Pharmaceutical Management Agency (Pharmac) was created in 1993. Unusual in international terms, Pharmac's objective is to work within a fixed budget while ensuring the New Zealand public receives an adequate range of government-subsidised medicines. Following its 20th anniversary, this article reflects on Pharmac's development and role within the New Zealand health system, various changes over time to the agency's scope and activities, its performance and its present challenges.

Identifying priority medicines policy issues for New Zealand: a general inductive study

OBJECTIVES

To identify priority medicines policy issues for New Zealand.

SETTING

Stakeholders from a broad range of healthcare and policy institutions including primary, secondary and tertiary care.

PARTICIPANTS

Exploratory, semistructured interviews were conducted with 20 stakeholders throughout New Zealand.

PRIMARY AND SECONDARY OUTCOME MEASURES

The interviews were digitally recorded, transcribed and coded into INVIVO 10, then compared and grouped for similarity of theme. Perceptions, experiences and opinions regarding New Zealand's medicines policy issues were recorded.

RESULTS

A large proportion of stakeholders appeared to be unaware of New Zealand's (NZ) medicines policy. In general, the policy was considered to offer consistency to guide decision-making. In the context of Pharmaceutical Management Agency's (PHARMAC's) fixed budget for procuring and subsidising medicines, there was reasonable satisfaction with the range of medicines available-rare disorder medicines being the clear exception. Concerns raised were by whom and how decisions are made and whether desired health outcomes are being measured. Other concerns included inconsistencies in evidence and across health technologies. Despite attempts to improve the situation, lower socioeconomic groups (including rural residents) Māori and Pacific ethnicities and people with rare disorders face challenges with regards to accessing medicines. Other barriers include, convenience to and affordability of prescribers and the increase of prescription fees from NZ$3 to NZ$5. Concerns related to the PHARMAC of New Zealand included: a constraining budget; non-transparency of in-house analysis; lack of consistency in recommendations between the Pharmacology and Therapeutics Advisory Committee. Constraints and inefficiencies also exist in the submission process to access high-cost medicines.

CONCLUSIONS

The results suggest reasonable satisfaction with the availability of subsidised medicines. However, some of the major challenges include access to medicines in vulnerable groups, increasing costs and demand for new medicines, access to prescribers, budgetary constraints, cultural and health literacy, patient affordability and evidence requirement for gaining subsidy for medicines.